Biliary Colic
Risk factors
- Constant dull pain and not colicky
- In RUQ/Epigastrium radiating to the back - right shoulder blade
- Lasts 30min - 6h
- Postprandial or nocturnal
- Hormonal or neural stimuli forcing a stone/sludge in the GB outlet
- The 5 F's
- Pregnancy (or history of one)
- Oral contraception - high doses of Oestrogen therapies
- Family history of gall stones
- Recent weight loss (bariatric surgery)
- Crohn's disease or IBS
- Cirrhosis
- Medications: Ceftriaxone, Octreotide
- Elderly patients are more likely to go from asymptomatic to serious complications without biliary colic
Clinical presentation
Uncomplicated gall stone disease
What is cholecystitis?
- Biliary colic
- Diaphoresis
- Nausea and vomiting
- Atypical symptoms: chest pain; nonspecific abdominal pain; bloating; heartburn; belching; nausea and vomiting with no biliary colic; fullness after meals
- Acute (calculous) cholecystitis
- Acalculous cholecystitis
- Chronic cholecystis
Clinical presentation
Biliary tract disease
Acute cholecystitis
- RUQ/epigastric pain > 6h
- Pyrexia
- Tachycardia
- Nausea and vomiting
- Anorexia
- History of food ingestion 1h or more prior to symptoms
- Possible signs of sepsis
- Murphy's sign
Facts
- Asymptomatic gall stones
- Biliary colic
- Cholecystitis
- Choledocholithiasis
- Cholangitis
- Mirrizi syndrome
- Cholelithiasis - gall stones in the gall bladder and biliary tree
- Common for western countries
- 15% of UK adults (6% men and 9% women
- 80% asymptomatic and 20% with complications
Laboratory studies
Biliary Colic and Acute Cholecystitis
Management of acute cholecystitis
Polyp vs gall stone
Imaging
- Mirizzi Type II - erosion from the calculus from the cystic duct into the common hepatic duct or CBD producing cholecystocholedochal fistula
Note the acoustic shadow!
Ultrasonography
- Sensitivity for gall stones is 84% and specificity 99%
- For diagnosis of cholecystitis 88% and 80% respectively
- Gall bladder wall thickening (> 4 - 5mm) or oedema (double wall sign)
- Sonographic Murphy's sign
- The accuracy of transabdominal ultrasound is operator dependent!
Sludge
No echoic shadow! Gravity dependent.
- Hospital admission for supportie care
- Fluid resuscitation/replacement, correction of electrolytes
- Pain relief
- Antibiotics
1st line - Co-amoxiclav + Gentamicin
2nd line - Co-tromoxazole + Metronidazole + Gentamicin
Categorization of patients with gall stones
What is Mirizzi syndrome?
- Category 1 - gallstones on imaging studies but without symptoms (incidental gall stones)
- Category 2 - typical biliary symptoms and gall stones on imain studies with no evidence of complications (uncomplicated gall stone disease)
- Category 3 - atypical symptoms and gall stones on imaging studies
- Category 4 - typical biliary symptoms but with no gall stones on imaging studies
- Type I - compression of the common hepatic duct or common bile duct by a stone impacted in the cystic duct or Hartman's pouch